The effect of chronic digitalization on pump function in systolic heart failure

Quantitative evaluation of drug or device effects on ventricular remodeling as predictors of therapeutic effects on mortality in patients with heart failure and reduced ejection fraction: a meta-analytic approach

OBJECTIVES

The purpose of this study was to quantitatively assess the relationship between therapy-induced changes in left ventricular (LV) remodeling and longer-term outcomes in patients with left ventricular dysfunction (LVD).

BACKGROUND

Whether therapy-induced changes in left ventricular ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV) are predictors of mortality in patients with LVD is not established.

METHODS

Searches for randomized controlled trials (RCTs) were conducted to identify drug or device therapies for which an effect on mortality in patients with LVD was studied in at least 1 RCT of > or = 500 patients (mortality trials). Then, all RCTs involving those therapies were identified in patients with LVD that described changes in LVEF and/or volumes over time (remodeling trials). We examined whether the magnitude of remodeling effects is associated with the odds ratios for death across all therapies or associated with whether the odds ratio for mortality was favorable, neutral, or adverse (i.e., statistically significantly decreased, nonsignificant, or statistically significantly increased odds for mortality, respectively).

RESULTS

Included were 30 mortality trials of 25 drug/device therapies (n = 69,766 patients; median follow-up 17 months) and 88 remodeling trials of the same therapies (n = 19,921 patients; median follow-up 6 months). The odds ratio for death in the mortality trials was correlated with drug/device effects on LVEF (r = -0.51, p < 0.001), EDV (r = 0.44, p = 0.002), and ESV (r = 0.48, p = 0.002). In (ordinal) logistic regressions, the odds for neutral or favorable effects in the mortality RCTs increased with mean increases in LVEF and with mean decreases in EDV and ESV in the remodeling trials.

CONCLUSIONS

In patients with LVD, short-term trial-level therapeutic effects of a drug or device on LV remodeling are associated with longer-term trial-level effects on mortality.

Prognostic implications of echocardiography in advanced heart failure

PURPOSE OF REVIEW

The growing epidemic of systolic congestive heart failure mandates strategies to identify accurately people with high morbidity and mortality. Echocardiography remains the most widely available noninvasive tool for the assessment of cardiac structure, function, and hemodynamics. Clinical data paired with echocardiographic analysis in patients with systolic heart failure obtained from a variety of investigations have allowed for the evaluation of this modality as a prognostic tool.

RECENT FINDINGS

Detailed appraisal of the literature has revealed five distinct, easy-to-evaluate echocardiographic parameters that may assist clinicians to segregate high-risk patients. The presence of or the inability to modify a left ventricular ejection fraction less than 25%, impaired right ventricular function (assessed by any of four methods), left ventricular end-diastolic dimension greater than 6.5 to 7 cm, a restrictive mitral inflow, or pulmonary hypertension (peak tricuspid regurgitant velocity >2.5 m/s) should alert clinicians of patients with high morbidity (recurrent congestive heart failure admission, arrhythmia, impaired functional capacity) and mortality. Particularly important among these variables is the presence of a restrictive mitral inflow pattern.

SUMMARY

Detailed analysis of two-dimensional and Doppler data routinely obtained from echocardiograms has established prognostic implications among patients with systolic heart failure. Although prospective clinical trials are lacking, the use of echocardiography to segregate risk should be incorporated into current strategies to treat congestive heart failure and influence clinical listing for cardiac transplantation.